Is America turning on birth control?

Birth control in the US right now is full of contradictions.

Access to contraceptives has never been easier. Many states have passed legislation to allow pharmacists to prescribe and dispense hormonal contraceptives directly to individuals, instead of requiring a doctor’s prescription first. Telehealth services have helped make it easier to find different contraceptive methods in more rural parts of the country. The first over-the-counter birth control pill, Opill, hit pharmacy shelves in early 2024.

Yet birth control is also facing cultural backlash. Social media platforms are awash with testimonials from people tossing aside their contraceptives in fear and sometimes anger, saying hormones are affecting their bodies or changing their personalities. Meanwhile, influencers are spreading misinformation about hormonal birth control, like that birth control causes long-term hormone disruption or causes cancer.

It’s a weird time to talk about birth control. But understanding the current cultural moment requires more than just agreeing that birth control is good and that those who decry it are wrong.

Rather, it’s worth interrogating where people’s dissatisfactions come from, and tracing how legitimate experiences with and worries about hormonal contraceptives can lead people toward alternate (and often scientifically dubious) sources of education about their bodies.

A history of harm

This backlash against birth control is partially related to growing conversations around neglected issues in women’s health. In the past 10 years, for example, doctors have finally started to take IUD insertion pain seriously. There’s now wider recognition of how distressing symptoms of perimenopause and menopause can be, and conditions like endometriosis are finally getting the research it deserves.

Historically, “women and gender minorities are a medically underserved and medically mistreated population,” says Kate Clancy, a human reproductive ecologist and anthropologist at the University of Illinois, and the author of Period: The Real Story of Menstruation. 

Many people with uteruses either have had or know someone who has had horrible experiences with health care that has diminished their trust in medicine, she says — so it makes sense that when people consider hormonal contraception and the possibility of side effects they start to question, “Is this really good for me?”

Racist and classist prejudices also shaped how doctors counseled people on birth control methods over the past 20 years. In the late 2000s, after the first hormonal IUD, Mirena, and the first hormonal implant, Implanon (which later became Nexplanon) were approved for use in the US. At that time, “the family planning community became very enamored with the high levels of effectiveness of those methods,” says Christine Dehlendorf, director of the Person-Centered Reproductive Health Program at the University of California San Francisco.

Doctors began, sometimes inappropriately, pushing these long-acting reversible contraception (LARC) methods on patients, or strongly objecting when people wanted to quit these methods, without listening to or trying to understand their reasoning. There was a sense that this “LARC first” strategy could protect people — especially low-income communities and communities of color — from their own undesired fertility, Dehlendorf says.

It was a demonstration of how, in the medical community, “we haven’t always prioritized reproductive autonomy in the way that we should,” Dehlendorf says. And when people sense their medical providers are acting paternalistically and not prioritizing their own wants and needs, they start to distrust the medical system and begin looking elsewhere for health information. “That then leads somebody to be susceptible and vulnerable to mis- and disinformation.”

And misinformation is in no short supply. There’s a swell of mostly right-leaning influencers now who have gained followings by demonizing hormonal contraceptives and promoting “natural birth control” methods like counting the days since your last period, tracking internal bodily temperature, and assessing the quality of vaginal discharge to gauge when you may or may not be fertile.

Some, like conservative podcast host Alex Clark, spread further fear and mistrust of hormonal birth control by claiming that it hurts women’s fertility and turns some women bisexual, neither of which are supported by data. These attitudes are rife throughout the Make American Healthy Again (MAHA) movement — Surgeon General nominee Casey Means has called birth control pills a “disrespect of life.”

Part of why learning about natural birth control methods is so attractive is because it promises more intimate knowledge of the body that eliminates the need for “unnatural” interventions like hormonal contraception. And while people, no matter their political leanings, want to understand their bodies and how to gauge their own health, the desire to rely only on “natural” interventions for health is a huge feature of MAHA rhetoric.

For those who have tried hormonal birth control but felt blindsided by side effects that weren’t adequately explained by their doctors, natural birth control might feel like a simpler path forward.

Why we keep talking about side effects

The plain truth is that many people on hormonal birth control will experience side effects. And data show that the majority of people who choose to go off the pill or take out their IUDs (not counting those who do so to get pregnant) make that choice because of those unwanted side effects. Some side effects, like mood changes, can go away by themselves over time or disappear when you change the kind of birth control you take. But for others, like changes in your bleeding or vaginal discharge, all that doctors can offer is reassurance that what you’re experiencing is normal.

Despite the robust body of data and evidence showing that hormonal contraceptives are safe and effective, doctors have no way of predicting whether any one person will experience any number of side effects, says Dehlendorf — a reality that exists in all of medicine and that makes the conversation around birth control and side effects tricky. Moreover, people can have very different experiences on the same hormonal birth control with different dosing, and experiences with one method can differ in different life stages, like before or after a pregnancy.

On top of all that, people’s wants and needs are unique — not every person views every side effect as equally tolerable or intolerable. What one person might find to be a minor and livable side effect, another person might find a deal-breaker. Some patients come into the clinic wanting their birth control to halt their periods (having no period while on birth control is safe and not bad for you), says Bianca Allison, a teen-focused primary care pediatrician in North Carolina and fellow with Physicians for Reproductive Health. Others really want to make sure they keep having regular periods, as reassurance that they’re not pregnant.

Regardless of where your bar is, experiencing an unpleasant side effect you weren’t expecting can be shocking. When Clancy started on a hormonal IUD in her 40s, which she needed as an offset for the estradiol patch she began taking for perimenopause, she spotted. In fact, “for seven months straight, I bled every single day” she says. That’s not uncommon, and Clancy was lucky to have a doctor who had warned her. But a lot of people are completely taken aback by their side effects and dismissed when they express fear or concerns about these side effects, she says.

There are people who will argue to this day that you shouldn’t share the potential negative risks of medication because then patients won’t take it, Clancy says. “My research and the research of others indicate the absolute opposite — when you inform people, and they feel like they can actually trust you, they’re actually much more likely to listen to your recommendations,” Clancy says.

Every person interviewed for this piece brought this up as a key area where doctors and other medical professionals can do a better job supporting patients, emphasizing that people want their doctors to proactively explain possible side effects, and what strategies are available to alleviate them. 

Birth control is for preventing pregnancy, yes. But there’s also a bigger picture.

When the first birth control pill was in development in the 1950s, women clamored to their doctors wanting to know how to get their hands on it. Early feminists like Margaret Sanger and Katharine McCormick argued that having control of one’s fertility was a necessary component of the emancipation of women. And research suggests that’s true. Access to reliable birth control has been shown to increase women’s earnings, allow them greater educational attainment, and decrease their risk of falling into poverty.

And there’s really no contraceptive more reliable than hormonal options. The American College of Obstetricians and Gynecologists says that birth control pills are about 93 percent effective with typical use. IUDs and contraceptive implants are the most reliable reversible contraceptives with 99 percent effectiveness, while condoms and fertility awareness methods (like counting the days since your last period or measuring body temperature to approximate when you might be fertile) are just about 87 and 77 percent effective, respectively.

That said, the pitfalls of the “LARC first” approach teach us that the ultimate goal of birth control should not be only to prevent pregnancy, but to help people live the sexual and reproductive lives they want to lead, says Allison.

Just because one birth control method has lower effectiveness doesn’t mean it is an inferior choice for all people. If a person really doesn’t want to be on hormones because of past experiences, and feels ambivalent about the risks of pregnancy, then fertility awareness methods alone might be okay for them, she says. But if they’re choosing to not be on hormones because of misinformation about long-term health effects, or if they think it’ll be as effective and easy as the pill at preventing pregnancy, then that’s something to talk about and maybe correct.

Some worry that politicized attitudes toward birth control will flatten people’s understanding of contraceptives, and create a divide where people who trust and use hormonal contraceptives are “good” and those who don’t are “bad” or vice versa, says Clancy. But the desire to learn about how different contraceptives affect the body — and to critically assess whether they’re right for you — should not be partisan. And no one method to control fertility should be demonized or given absolute primacy.

Hormonal contraceptives are a remarkable, life-changing tool — that often come with trade-offs that others find unacceptable. Being clear-eyed about birth control requires us to understand that the way people assess these tradeoffs and make their decisions can be layered and individual. 

If we had a society with easily available contraception, easily available education for all the pros and cons for all the different methods, and easily available abortion, we’d still have a diverse array of people picking all the different options, says Clancy. There are nuances and valid critiques to each of them, “but I 100 percent think that we should have complete unfettered access to them if we need them.”

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